In line with the upcoming Breast Cancer Awareness Month (1st – 31st October), I thought it apt to share a personal story relating to one of my closest and dearest friends: Dr. Erica Schultz. Erica and I go a long way back – when we were both earning our Doctorate in Naturopathic Medicine at Bastyr University, in Kenmore, Washington. Our friendship started on the very first day of medical school. Sparked by the intimate act of listening to each other’s heartbeats through a stethoscope, our special connection was then solidified by burning the midnight oil studying for exams, traversing across the globe, and having deep, intellectual discussions about health and naturopathic medicine over the subsequent years.
Thinking back to the day I met Erica is a bittersweet experience … she’s just recently passed away from invasive ductal triple-negative breast cancer that eventually metastasized to her brain and spine (i.e., leptomeningeal disease). Despite having led an incredibly healthy lifestyle, it turned out that Erica had the BRCA1 gene mutation. That significantly increased her risk of having breast cancer. Couple that with late detection, and most unfortunately, her breast cancer had already gotten to stage 3 by the time she was diagnosed. I was by her side through her last months and days of her life – listening to her heartbeat right till the moment it stopped, perhaps the most appropriate way to bid farewell considering the manner through which we’d first connected all those years ago. And so, as a tribute to Erica, I thought I’d spread awareness to breast cancer, and the importance of regular screening, through her story.
What is Breast Cancer?
Cancer occurs when changes (more specifically, ‘mutations’) occur in genes that regulate cell growth (1, 2). The mutations allow cells to divide and multiply in an uncontrolled way. And so, breast cancer is cancer that develops in breast cells. There are 8 main types of breast cancer, which are further broken down into 2 main categories: 'invasive' or 'non-invasive' (i.e., 'in situ') (3, 4, 5, 6). Find a brief elaboration on each below.
Ductal Carcinoma In Situ (DCIS)
Ductal carcinoma in situ (DCIS) is non-invasive cancer where abnormal cells have been found in the lining of the breast milk duct. These cells have not spread outside of the ducts into the surrounding breast tissue. As such, DCIS is considered a very early cancer that's highly treatable.
Invasive Ductal Carcinoma (IDC)
Invasive Ductal Carcinoma (IDC) is invasive cancer where atypical cancer cells that began forming in the milk ducts have spread beyond – into other parts of the breast tissue. These invasive cancer cells can also spread to other parts of the body. Dr. Erica was originally diagnosed with IDC.
Lobular Carcinoma In Situ (LCIS)
Lobular Carcinoma In Situ (LCIS) is non-invasive cancer where abnormal cells are found in the breast's lobules (i.e., milk-producing glands). These cells have not spread into the surrounding breast tissue.
Invasive Lobular Cancer (ILC)
Invasive Lobular Cancer (ILC) refers to breast cancer that begins in the breast's lobules and spreads to surrounding normal tissue. These atypical cells can also spread through the blood and lymph systems to other parts of the body.
Triple Negative Breast Cancer (TNBC)
If you'd recall, this was the diagnosis my dear friend, Erica, received. A diagnosis of Triple Negative Breast Cancer (TNBC) means that the 3 most common types of receptors known to fuel most breast cancer growth – estrogen, progesterone, and the HER-2 (i.e., neu) gene – are not present in the cancer tumor. TNBC is known to be more aggressive and challenging to treat.
Inflammatory Breast Cancer (IBC)
Inflammatory Breast Cancer (IBC) is aggressive and fast-growing breast cancer in which atypical cells infiltrate the skin and lymph vessels of the breast. It often produces no distinct lump or tumor that can be felt and isolated within the breast.
Metastatic Breast Cancer (MBC)
As implied by its name, Metastatic Breast Cancer (MBC) is a Stage 4 breast cancer that’s spread to other parts of the body – usually including the lungs, liver, bones, or brain.
Breast cancer during pregnancy
It is possible to be diagnosed with breast cancer during pregnancy. That said, it's an extremely rare condition – with research showing that breast cancer being reported 1 in every 3,000 pregnancies. It's also worth noting that the cancer isn't caused by pregnancy.
Breast cancer stages
Breast cancer stage is usually expressed as a number on a scale of 0 through 4, with stage 0 describing non-invasive cancers that remain within their original location – and stage 4 describing invasive cancers that have spread outside the breast to other parts of the body. All doctors and treatment facilities determine cancer's stage according to the following clinical characteristics (in line with the American Joint Committee on Cancer's universal breast cancer staging guidelines) (7):
- The size of the cancer tumor – and whether it has grown into nearby tissue
- Whether the cancer is in the lymph nodes
- Whether cancer has spread to other parts of the body beyond the breast
- Tumor grade: A measurement of how much the cancer cells look like normal, healthy cells
- Estrogen- and progesterone-receptor status: Do the cancer cells have receptors for the hormones estrogen and progesterone?
- HER2 status: Are the cancer cells making too much of the HER2 protein?
- Oncotype DX score: If the cancer is estrogen-receptor-positive, HER2-negative, and there is no cancer in the lymph nodes
Breast cancer survival rate
While breast cancer survival rates vary according to age, race, and ethnicity, one of the greatest determinants is still an individual's stage of breast cancer at the time of diagnosis (8, 9). In general, the earlier breast cancer is diagnosed and treated (i.e., early stages), the higher the chances for long-term survival. That's because the abnormal cells are less likely to have metastasized – and spread to other body parts beyond the breast.
Looking for exact breast cancer survival rates (10, 11)? The 5-year survival rate for women diagnosed with localized breast cancer is about 99%. However, for women diagnosed with regional breast cancer (where the cancer's spread outside to nearby lymph nodes), that figure drops to about 86%. Finally: women who're diagnosed with distant breast cancer – when it's spread to other parts of the body (e.g., liver, lungs, or bones) – have about a 28% likelihood of surviving for 5 years. My valiant friend, Erica, fought a heroic battle but ultimately surrendered a little over a year after her original diagnosis.
Risk factors for breast cancer
Your risk for developing breast cancer increases with age. Most invasive breast cancers are found in women over age 55 years.
White women are 100 times more likely to develop breast cancer than white men, and Black women are 70 times more likely to develop breast cancer than Black men.
Alcohol use disorder raises the risk of developing breast cancer.
Being overweight is associated with an increased risk of breast cancer – especially for women after menopause. Fat tissue is the body's primary source of estrogen after menopause; having more fat tissue means having higher estrogen levels, increasing breast cancer risk.
If a close female relative (e.g., mother, grandmother, sister, or daughter) has had breast cancer, you have an increased risk for developing it.
Women who have the BCRA1 and BCRA2 gene mutations (as Erica did) are more likely to develop breast cancer than those who don’t.
Breast cancer prevention
As you can tell, many of the risk factors for breast cancer are beyond your control – including your age, family history, and medical history. That said, there are a handful of risk factors you can control. And that’s what we’ll focus on. To lower your risk of developing breast cancer as much as possible, you’d want to lead a healthy lifestyle; that means: 1) keeping your body weight in a healthy range for your height and frame, 2) eating a healthy diet (i.e., plenty of fruits and vegetables and omega-3 fatty acids), 3) limiting your consumption of saturated fats, processed meats, charred or smoked foods, and 4) cutting down on the amount of alcohol you drink.
About breast cancer screening
But what about all the risk factors you can't control? Well, in addition to regular self breast exams, you can hedge against that by going for regular screening for breast cancer. Talk with your doctor to determine your risk factors, when you should be screened, and with what frequency. The earlier you catch breast cancer, the better your prognosis. Common breast cancer screening methods include (16, 17, 18):
A mammogram uses a machine designed specifically to take x-rays of the breasts. It has 2 plates that flatten the breast to spread the tissue apart – helping to give a better picture and lowering the amount of radiation needed. While a mammogram can be uncomfortable, it’s still considered one of the best (i.e., accurate) tools doctors have to screen healthy women for breast cancer.
Magnetic resonance imaging (MRI)
A procedure that uses a magnet, radio waves, and a computer to make detailed pictures of the tissues inside the breast. MRI does not use any X-rays. An MRI is the recommended screening method for women who have a high risk of breast cancer. That said, it’s also worth noting that an MRI is more likely than mammography to find a breast mass that is not cancer (i.e., false positive).
It is important to note that Erica underwent a double mastectomy and began the reconstruction process during her journey. Sadly, we later learned that it was unsafe for her to undergo an MRI due to the reconstruction expanders that had been placed inside, and ultimately she had to undergo yet another surgery to remove the expanders in order to get the MRI imaging she so desperately needed for answers on her current prognosis. An overlook in care no woman should have to experience.
Also called thermal imaging. Thermography uses a special camera to measure the temperature of the skin on the breast’s surface. It involves no radiation. It’s been found that skin temperature can go up in the presence of a cancer tumor and while not a replacement for regular mammogram screening, should be considered a complementary tool in breast cancer diagnosis. I personally aim to get thermography (at least the breast region) done yearly.
Bottom line? Go for mammography unless otherwise advised by your doctor. You can also choose to do a breast self-examination once a month, at the same time each month – this can help familiarize you with how your breasts usually look and feel so that you're aware of any changes that occur (19).
Go for a medical checkup
Closing off, I'd just like to reiterate the importance of going for regular medical checkups and breast cancer screenings. I wish I could turn back the hands of time, as I would love nothing more than to be able to hear her beautiful heart beat one more time. Early signs of breast cancer can be a lump in a breast, a painful breast or armpit, or a discharge from the nipples. It pains me to say that Erica had, in actuality, noticed a lump a year before her diagnosis – but mistakenly thought that it was likely just scar tissue from a breast augmentation surgery she had a few months prior. When she originally spoke to her surgeon about it, he informed her he saw nothing abnormal during the procedure. Ultimately a mammogram was recommended but by that time, the fast growing cancer was already stage 3. So, I can't say this enough: early detection is a lifesaver. Be sure to tell that to your loved ones, too.